ILN Tibia

1. Controversies in the
Intramedullary
Nailing of Proximal and Distal
Tibia Fractures
Prpeared by Dr Madan Mohan,
Consultant in Orthopaedics, KIMS Trivandrum
Based on the
Instructional Course Lecture of JAAOS
October 2014, Vol 22, No 10

2. Proximal Tibia

3. •The choice between plating and IM nailing
when either may be applicable is a matter of
debate
•Although IM nailing of the tibia has become the
standard of care for most tibial diaphyseal
fractures, treating proximal tibia fractures with
IM nails has proved to be particularly difficult

4. •With proximal fractures, increased tension on
the knee extensor mechanism in the flexed
position exaggerates the deforming forces
•The anterior pull on the tibial tubercle results in
a flexion and anterior translation deformity.
•A valgus deformity is commonly seen, as well,
likely the result of imbalance associated with
the hamstring and anterior compartment
musculature

5. Reduction Techniques and Tips: Supplemental
plates
•Reducing the fracture in an extended position
and applying a unicortical plate that does not
impede the passage of an IM nail
•This often requires open exposure of the
fracture and release of the fracture hematoma
as well as periosteum stripping, which may
compromise the healing potential

6. Reduction Techniques and Tips: Reduction
Forceps
•Alignment can be achieved and secured using
percutaneously applied reduction forceps.
•This technique requires careful attention to soft-
tissue compromise and the location of
neurovascular structures.
•Oblique and spiral fractures are typically more
amenable to this technique.

7. Reduction Techniques and Tips: Blocking
Screws
Screws placed adjacent to the
nail from anterior to posterior
help prevent coronal plane
deformity

8. Reduction Techniques and Tips: Blocking
Screws
Screws placed posterior to the
nail in the coronal plane help
prevent procurvatum or
flexion

9. Reduction Techniques and Tips: Shanz Pins and
Femoral Distractors
•Percutaneous use of Schanz pins as
joysticks may aid in the reduction of
the fracture.
•Use of a femoral distractor is an
extension of this concept.
•The distractor is commonly applied
medially with posterior positioning
of the Schanz pins

10. Reduction Techniques and Tips: Nail Starting
Point and Design
• If the surgeon does not accurately introduce the nail
in the proximal fragment, directly in line with the
diaphyseal canal, the alignment will be impossible to
maintain
• A more medial starting point will exaggerate valgus
deformity, and a more distal starting point will cause
procurvatum.

11. Lateral fluoroscopic image of the
knee demonstrating a starting point
obtained through a suprapatellar
approach for management of a
proximal tibia fracture. The circle
represents the ideal starting point.
The dashed line represents the ideal
trajectory through the starting point
that could be obtained with slightly
more knee flexion and a parapatellar
arthrotomy. The dotted line
represents the trajectory that the
suprapatellar approach provides with
the ideal starting point (too posterior)
unless the tibia can be translated
more anteriorly.

12. AP fluoroscopic image of the proximal tibia
demonstrating the starting point. Visualizing the
starting point on the AP view requires proper
rotation of the leg so that the lateral
condyle of the tibial plateau is superimposed over
50% of the width of the fibular head. Proper
trajectory of the guidewire is along the lateral side
of the diaphysis; the final nail position will be against
the lateral cortex because of the triangular cross
section of the isthmus. The larger line represents
the ideal path of the nail. The three thinner lines
represent the medial and lateral edges of the fibula
(arrowheads) and the resultant midline of the fibula,
which should be aligned with the lateral tibial
plateau on a properly rotated AP image

13. Suprapatellar Nailing
• Tornetta and Collins revisited nailing in the
semiextended position in 1996
• Combining nailing in the semiextended position with
the various techniques already mentioned can be very
effective.
• The availability of alternative surgical sites is a
reported advantage. This can be particularly useful in
the setting of traumatized infrapatellar skin.

14. Suprapatellar Nailing
Theoretic advantages may exist that
mitigate knee pain with the
suprapatellar technique, including
limiting superficial surgical
dissection in the region of the
proximal tibia and the avoidance of
the infrapatellar branch of the
saphenous nerve

15. Suprapatellar Nailing
•Concerns include risk of injury to patellar or
femoral trochlear cartilage, risk of iatrogenic
injury to other intraarticular structures, risk of
joint sepsis or of intra-articular retained reaming
debris, and the challenge of nail removal.
•Clinical reports are sparse

16. Distal Tibia

17. •The difficulty in treating distal tibia fractures is
related to the ability to attain and hold the reduction
of the fracture while maintaining adequate fixation
until healing has occurred.
•Other factors that may play a role are the
discrepancy between the diaphyseal and
metaphyseal bone diameters and the short-segment
distal fragment, which makes achieving and holding
the reduction difficult.

18. • The advantages of nailing, which include minimal soft
tissue dissection or exposure at the fracture site, may
now be diminished with these minimally invasive
techniques.
• Excellent healing rates and union rates have been
reported using MIPPO techniques
• Nailing can be performed acutely; however, if the plan
is for plating, it is advisable to wait for swelling to
diminish

19. •The starting point of the nail is similar to that for
any other tibial nail; however, the ending point
of the guidewire must be center-center on both
AP and lateral fluoroscopy views to prevent
deformity.
•Unlike diaphyseal fractures, nail insertion in
distal metaphyseal fractures does not result in
fracture reduction.

20. •If intra-articular extension is noted, it should
be reduced and stabilized first, before
reaming; the goal is to prevent
displacement of the articular surface while
attempting nailing.
•Kirschner wires for use with cannulated
screws are inserted to capture the articular
fragments and are placed such that they do
not block the path of the nail (usually distal)

21. •Use of blocking screws may be required to guide
passage of the nail into the desired location by
blocking passage of the nail into undesirable
location.
•Blocking screws are typically inserted on either
side of the nail to guide its passage to the
center-center position

22. Bone reduction clamps may
be used for percutaneous
application to reduce and
hold the fracture; small
incisions for the tines of the
clamps are preferable to
poking through the skin;
this allows closure at the
end and will prevent
drainage of hematoma
through these so-called
poke holes

23. •Performing the distal locking first is
recommended to hold reduction
•Use of three (or the maximum number
possible) distal locking screws is helpful in
increasing the fixation strength and holding
the reduction

24. • Inserting a Schanz pin parallel to the joint in the distal
tibia posterior to the midline will allow both traction
and fracture reduction in conjunction with an external
distractor and a proximal tibial pin
• Blocking screws can be inserted percutaneously and
act to decrease the width of the metaphyseal
medullary canal, facilitate reduction, prevent nail
translation, and increase the strength of the fixation
construct.